PENANGGULANGAN TB NASIONAL TB.

09

FORMULIR RUJUKAN / PINDAH PASIEN TB

Nama Instansi pengirim : ....................................................................... Telp. ..............................

Nama Instansi yang dituju : .................................................................... Telp. ..............................
Nama Penderita : ..........................................................................................................................
Jenis Kelamin : L / P Umur : .................... Thn
Alamat Lengkap : ..........................................................................................................................
No. Reg. TB. Kabupaten : ...............................................................................................................
Tanggal mulai berobat : ...............................................................................................................
Jenis pengobatan : Klasifikasi / Tipe pasien :

Kategori 1 Kasus Baru ( BTA positif )

Kategori 2 Kasus Kambuh / Gagal ( BTA positif )

Kategori Anak Kasus Baru ( BTA negatif / ronsen positif )

Lain-lain, sebutkan Pindahan

Lain-lain

Jumlah dosis ( obat ) yang sudah diterima

Tahap awal : ........................................................
Tahap Lanjutan : ........................................................
Pemeriksaan ulang dahak terakhir : Tanggal : ............................................... Hasil : ......................

..............................., ...............................

( ............................................. )

.....................................................................................................................................................

PENGEMBALIAN PENDERITA RUJUKAN / PINDAH

( Dikembalikan ke Unit pengirim )

Nama Penderita : ...................................................... No. Reg. TB Kab / Kota : ...........................

Jenis Kelamin : L/P Umur : ................... tahun

Tanggal penderita melapor : ........................................................................................................

Nama unit pelayanan kesehatan ( tempat berobat baru ) : ............................................................

.................................................................................................... Telp. .......................................

..............................., ...............................

( ............................................. )